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International Journal for Equity in Health Biomed Central International Journal for Equity in Health BioMed Central Research Open Access Access to health care in relation to socioeconomic status in the Amazonian area of Peru Charlotte Kristiansson*1, Eduardo Gotuzzo2, Hugo Rodriguez3, Alessandro Bartoloni4, Marianne Strohmeyer4, Göran Tomson1 and Per Hartvig5 Address: 1IHCAR (Div International Health), Karolinska Institutet, Stockholm, Sweden, 2Inst Med Trop A von Humboldt, Universidad Peruana Cayetano Heredia, Lima, Peru, 3Health Directorate of Loreto, Iquitos, Loreto, Peru, 4UFDID, University of Florence, Florence, Italy and 5Dept Pharmacology and Pharmacotherapy, Farma, University of Copenhagen, Denmark Email: Charlotte Kristiansson* - [email protected]; Eduardo Gotuzzo - [email protected]; Hugo Rodriguez - [email protected]; Alessandro Bartoloni - [email protected]; Marianne Strohmeyer - strohmeyerm@aou- careggi.toscana.it; Göran Tomson - [email protected]; Per Hartvig - [email protected] * Corresponding author Published: 15 April 2009 Received: 22 April 2008 Accepted: 15 April 2009 International Journal for Equity in Health 2009, 8:11 doi:10.1186/1475-9276-8-11 This article is available from: http://www.equityhealthj.com/content/8/1/11 © 2009 Kristiansson et al; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Abstract Background: Access to affordable health care is limited in many low and middle income countries and health systems are often inequitable, providing less health services to the poor who need it most. The aim of this study was to investigate health seeking behavior and utilization of drugs in relation to household socioeconomic status for children in two small Amazonian urban communities of Peru; Yurimaguas, Department of Loreto and Moyobamba, Department of San Martin, Peru. Methods: Cross-sectional study design included household interviews. Caregivers of 780 children aged 6–72 months in Yurimaguas and 793 children of the same age in Moyobamba were included in the study. Caregivers were interviewed on health care seeking strategies (public/private sectors; formal/informal providers), and medication for their children in relation to reported symptoms and socio-economic status. Self-reported symptoms were classified into illnesses based on the IMCI algorithm (Integrated Management of Childhood Ilness). Wealth was used as a proxy indicator for the economic status. Wealth values were generated by Principal Component Analysis using household assets and characteristics. Results: Significantly more caregivers from the least poor stratum consulted health professionals for cough/cold (p < 0.05: OR = 4.30) than the poorest stratum. The poorest stratum used fewer antibiotics for cough/cold and for cough/cold + diarrhoea (16%, 38%, respectively) than the least poor stratum (31%, 52%, respectively). For pneumonia and/or dysentery, the poorest used significantly fewer antibiotics (16%) than the least poor (80%). Conclusion: The poorest seek less care from health professionals for non-severe illnesses as well as for severe illnesses; and treatment with antibiotics is lacking for illnesses where it would be indicated. Caregivers frequently paid for health services as well as antibiotics, even though all children in the study qualified for free health care and medicines. The implementation of the Seguro Integral de Salud health insurance must be improved. Page 1 of 8 (page number not for citation purposes) International Journal for Equity in Health 2009, 8:11 http://www.equityhealthj.com/content/8/1/11 Background Methods Following health reforms in the 1980s and 1990s, many Study area Latin-American countries moved from universal coverage Population and socioeconomic structure (free health care financed by public funds) towards cost This survey was conducted in 2002 in two Peruvian com- recovery initiatives utilizing, for example, user fees and munities, Yurimaguas (Department of Loreto) and Moy- social insurances [1-3]. However, user fees have been obamba (Department of San Martin). In 2002, each shown to represent an important barrier to accessing community had a population of approximately 32000 health services, especially for poor people[4]. Strategies inhabitants. Both departments represent one of the most including fee exemption – aimed at mitigating exclusion- underprivileged areas of Peru – the Amazonian region. ary effects – have proven to be stigmatizing and costly Approximately 55% of the population lives below the since administrational measures are needed to identify poverty line, and 15% in extreme poverty and the major- the poor [5,6]. It is likely, therefore, that if targeted inter- ity of the working population survive on subsistence farm- ventions are to be effective in reaching the poor, special ing [15]. Yurimaguas is less accessible than Moyobamba strategies need to be more carefully outlined [7,8]. which has a better infrastructure and is easily reached from the surrounding communities. In Peru, inequity in health service utilization during the late 1990s was shown for adults [9] but no corresponding Health services figures for children have been presented. This lack of The study was conducted in urban settings where geo- attention is surprising since death resulting from infec- graphical distances to health facilities are small. Yurim- tious disease remains a major health problem for children aguas has one Ministry of Health (MoH), a public in low and middle income countries. In Peru, the most hospital, a Local Committees for Health Administration common causes of mortality among children under five (CLAS) Maternal Health Centre [16] and two health posts. years of age remain acute respiratory tract infections [10]. In addition there is a Social Security Institute hospital (ES Furthermore, several studies have shown a well-estab- SALUD). In Moyobamba, there are three health posts and lished connection between socioeconomic status and one health center. At the time of the study, the hospital in health [11,12], where proximate factors, such as health Moyobamba belonged to ES SALUD system, and the MoH prevention, nutrition and care, have been directly linked facilities either paid the ES SALUD hospital for treatment to socioeconomic status [13]. These studies make clear of public sector patients or referred patients to the nearby that in addition to ill health, the costs for health care and city of Tarapoto. At both study locations, the hospital and medicines further impoverish vulnerable population health center employees mainly included medical doc- groups [14], poor children notwithstanding. tors, while the health posts were staffed exclusively with nurses, midwives and health technicians. The Seguro Integral de Salud state health insurance (SIS) was implemented in Peru in 2001 and at the time of this All licensed, private pharmacies – nine in Yurimaguas and study offered free of charge health care and pharmaceuti- fifteen in Moyobambas – had trained pharmacists on cals, such as antibiotics, to children in the study area, their staff list. However, in most cases, these pharmacies regardless of socioeconomic status. Access to health serv- were run by assistants without formal education. Offi- ices and pharmaceuticals following policy implementa- cially, antibiotics could only be sold by pharmacies, but in tion has improved, at least theoretically through the SIS, practice they were also bought without prescription, avail- for children from all socioeconomic groups; however, pre- able at the market place, in food stores or from traditional sumptive improvements in the health seeking behavior of healers. poor children have yet to be empirically analyzed or veri- fied. The question of verifiable improvements becomes The SIS was created by merging the already existing Mater- even more essential when considering poor children who nal/Infant and School insurances. In theory, SIS provided have high geographic access to health facilities. The aim of health care and essential pharmaceuticals via the public this study, therefore, was to describe health care access – health care sector free of charge to those with low eco- measured as consultations with health professionals – nomic status, to pregnant women and to senior citizens, and antibiotic use in relation to socioeconomic status for according to insurance schemes specified by target group. children who recently presented symptoms of infectious In areas with a poverty level higher than 60%, such as the disease. Amazonian area, all children qualified for the insurance, irrespective of their parents' economic status. The insur- ance covered health care, including essential generic drugs and diagnostic services. Affiliation to the insurance was not, however, automatic and the children had to be regis- tered every calendar year at the hospital's SIS office. Page 2 of 8 (page number not for citation purposes) International Journal for Equity in Health 2009, 8:11 http://www.equityhealthj.com/content/8/1/11 Means of data collection an open-ended question and then probed by stating all Design and sampling symptoms in the questionnaire one by one while also The results presented in this paper were generated within explaining the symptoms. the ANTRES project, a collaborative research project funded by the EC INCO-DEV, ICA4-CT-2001-1001, A system for checking
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